Sudden Death After Heart Attacks (Part II)

From Richard N. Fogoros, M.D.
MADIT II and the appropriate use of the implantable defibrillator
Unfortunately, there has been no formal "indication" for using implantable defibrillators in heart attack survivors. These devices have been reserved for patients who have already had cardiac arrests from ventricular fibrillation, and who were fortunate enough to be resuscitated - a relatively very small population of individuals. The reticence to use implantable defibrillators in larger groups of patients was originally based on the "newness" of the therapy - did it really work as well as it was supposed to? - and on the fact that for the first decade or so of its use, the surgery necessary for implanting this device was a major undertaking. Today, when the necessary surgery is nearly as simple as implanting a standard pacemaker, and when the device has proven its effectiveness to an astounding degree, the reticence to apply it to larger groups is based on cost.
This week in the New England Journal of Medicine, such a study was reported. The MADIT II trial enrolled more than a thousand patients who had prior heart attacks and whose left ventricular ejection fractions (a measure of the pumping efficiency of the heart) was less than 30% were randomized to receive either standard medical therapy, or the same standard medical therapy plus the implantable defibrillator. The results were striking: patients who received the defibrillator experienced a 30% reduction in mortality compared to patients without the defibrillator. As a result of MADIT II, the FDA is being petitioned to allow use of the implantable defibrillator in heart attack survivors with reduced ejection fractions. The FDA is expected to grant this new indication relatively soon.
But based on the reaction of doctors and insurers to this new data, a sudden surge in defibrillator implantations may not occur.

Why preventing sudden death is low on everyone's priority list
Three reasons:
1) Insurance companies and the feds (i.e. Medicare) like sudden death. It is not only the cheapest way to die, but also its victims (most of whom have some form of underlying heart disease) immediately stop consuming precious health care dollars.
2) Doctors don't like to think about sudden death because doing something to prevent it is expensive.
3) Unlike AIDS, breast cancer, or the heartbreak of psoriasis, sudden death has no constituency among patient groups. By the time a person realizes it's a problem, he/she may have enough time to utter a gasp but certainly not enough time to found a political action committee. Patients simply aren't demanding that reluctant doctors implant these devices, or that insurance companies pay for them.
So for nearly everyone in the health care system, the course of least resistance - and the safest course of action - is simply to ignore the problem. Frankly, unless heart attack survivors specifically ask about the possibility of sudden death - which is a reasonably likely occurrence in many patients who have survived a heart attack - the topic is unlikely to come up.